Embed Size (px)
Citation preview
ASRG/1-WP/4 25/11/2019
International Civil Aviation Organization Annual Safety Report Group First Meeting (MID-ASRG/1) (Cairo, Egypt, 25 – 27 November 2019)
Agenda Item 2: Work Programme
REVIEW OF THE EIGHTH MID ANNUAL SAFETY REPORT
(Presented by the Secretariat)
SUMMARY
This paper presents the Eighth Draft Edition of the MID Annual Safety Report with the analysis of the accidents and incidents data, and identification of the key Focus Areas and related contributing factors in the MID Region, for review by the ASRG/1 meeting. Action by the meeting is at paragraph 3.
REFERENCES
- Draft Edition of 8th
Annual Safety Report
1. INTRODUCTION 1.1 The MID Annual Safety Report Team (MID-ASRT) was established through Decision 1/3 of the Regional Aviation Safety Group (RASG-MID/1) meeting, which was held in Cairo, Egypt, 18-19 September 2011. 1.2 The RASG-MID/7 supported the establishment of the ASRG, ASPIG, SEIG and AIIG and endorsed the revised RASG-MID Organizational Structure. However, the Annual Safety Report Group (ASRG) should resume the responsibilities according to the established Terms of Reference of the MID-ASRT. 1.3 The objective of the RASG-MID Annual Safety Report is to gather safety information from different stakeholders and to identify the main aviation safety risks in the Middle East Region in order to deploy mitigation actions for enhancing aviation safety in a coordinated manner. 2. DISCUSSION 2.1 The safety information presented in the Eighth Edition of the Annual Safety Report is based on the compilation and analysis of data provided by: The International Air Transport Association (IATA) and the International Civil Aviation Organization (ICAO), airline operators, and States.
ASRG/1-WP/4 - 2 – 2.2 The Annual Safety Report will be covered in the PPT/3.
2.3 Based on the analysis of the reactive and proactive safety information for the period 2014-2018, and in accordance with the agreed new methodology for the risk assessment, the Focus Areas are:
1. Runway Safety (RS)- (mainly RE and ARC during landing); 2. Loss of Control Inflight - (LOC-I); 3. Controlled Flight Into Terrain- (CFIT); and 4. Mid Air Collision- (MAC
2.4 The emerging risks, which have been identified, based on the analysis of the data available, are:
1. Fire/Smoke (non-impact) – (F-NI); 2. Wake turbulence; 3. Runway Incursion-(RI); 4. Bird Strike- (BIRD); and 5. Security- (SEC)
2.5 The regional average overall Effective Implementation (EI) in the MID Region (13 out of 15 States have been audited) is 75.23 %, which is above the world average 68.53% (as of 25 Sep 2019). Three (3) States are currently below EI 60.
2.6 The Draft of the ninth edition of the MID ASR will be presented to the ASRG/2 meeting for review (July 2020). Therefore, States are urged to provide necessary data to the ICAO MID Office, by March 2020 related to each occurrence category in Appendix A for the past 5 years (2015 – 2019) and using the template in Appendix B. 3. ACTION BY THE MEETING 3.1 The meeting is invited to:
a) review and update as deemed necessary, the Draft version of the 8th MID-ASR at Appendix C, in order to be presented to the RSC/7 meeting for endorsement; and
b) urge States and all Stakeholders to provide necessary safety data to the MID-ASRG for the development of the next Edition of the Annual Safety Report; and
c) endorse the following Draft Conclusion:
DRAFT CONCLUSION 1/1: SHARING OF SAFETY DATA ANALYSIS States are urged to provide the ICAO MID Office by March 2020 with the number of accidents, serious incidents and incidents, safety data analysis, and their associated safety recommendations related to each occurrence category in Appendix A for the past 5 years (2015 – 2019) and using the template in Appendix B
------------------
ASRG/1-WP/4 APPENDIX A
APPENDIX A
LIST OF FOCUS AREAS AND EMERGING RISKS TAXONOMY
Scope: State of Occurrence
The data to be collected be based on scheduled commercial operations involving aircraft having a Maximum Take-off Weight (MTOW) above 5700 kg.
Occurrence Category ADREP/CICTT taxonomy Remarks
Runway Excursion (RE)
Veer off or overrun off the runway surface.
Abnormal Runway Contact (ARC)
Any landing or take-off involving abnormal runway or landing surface contact.
Loss of Control-Inflight (LOC-I)
Loss of Control while, or deviation from intended flight path, in flight.
Including occurrences which lead to the LOC-I accident
Controlled Flight Into Terrain (CFIT)
Inflight collision or near collision with terrain, water, or obstacles without indication of loss of control.
Including occurrences which lead to the CFIT accident
MID Air Collision (MAC)/ NMACs
Airprox/TCAS Alerts, Loss of separation as well as NMAC or collisions between aircraft inflight.
(including, RPAS/Drones, Call Sign Confusion)
Fire/Smoke (F-NI) Fire or smoke in or on the aircraft, in flight, or on the ground, which is not the result of impact.
Runway Incursion (RI)
Any occurrence at aerodrome involving the incorrect presence of an aircraft, vehicle, or person on the protected area of a surface designated for landing and takeoff of aircraft.
System Component Failure –Non-Power Plant (SCF-NP)
Failure or malfunction of an aircraft system or component other than the power plant.
Turbulence Encounter (TURB)
In-flight turbulence encounter.
Mainly occurrences related to wake turbulence (Vortex)
ASRG/1-WP/4 APPENDIX A
A-2
Birdstrike (BIRD) Occurrences involving collisions/near collisions with bird(s).
Wildlife (WILD) Collision with, risk of collision or evasive action by an aircraft to avoid wild life on the movement area of an aerodrome.
System Component Failure- Power Plant (SCF-PP)
Failure or malfunction of an aircraft system or components related to the power plant.
Security related (SEC)
Criminal/Security acts which result in accidents or incidents (per Annex 13 to the Convention on International Civil Aviation).
Wind shear Flight into wind shear or thunderstorm
NB: States may share any other national safety concern.
----------------------
ASRG/1-WP/4 APPENDIX B
APPENDIX B
TEMPLATE FOR THE COLLECTION OF
ACCIDENT, SERIOUS INCIDENT AND INCIDENT DATA AND SAFETY ANALYSIS
Name of State: ……………………..
Traffic: Nb. of Departures per year [2015: …………] [2016: …………] [2017: …………] 2018: …………]2019: …………]
1- Occurrences: The data to be collected be based on scheduled commercial operations involving aircraft having a Maximum Take-off Weight (MTOW) above 5700 kg.
# Occurrence Category
2015 2016 2017 2018 2019
# Accidents
# Serious incidents
# Incidents
# Accidents
# Serious incidents
# Incidents
# Accidents
# Serious incidents
# Incidents
# Accidents
# Serious incidents
# Incidents
# Accidents
# Serious incidents
# Incidents
1 Runway Excursion (RE)
2 Abnormal Runway Contact (ARC)
3 Loss of Control-Inflight (LOC-I)
4 Controlled Flight Into Terrain (CFIT)
5 Mid Air collision (MAC)/ NMAC
6 Fire/Smoke (F-NI)
7 Runway Incursion- (RI)
8 System Component Failure-Non-Power Plant (SCF-NP)
9 Wake Turbulence
ASRG/1-WP/4 APPENDIX B
B-2
10
BIRD
11 Wildlife (Wild)
12 System Component Failure-Power Plant (SCF-PP)
13 Wind shear
States should provide the number of accident, serious incidents, and incidents related to each category mentioned in the template above for the past three years (2015-2018)
Scope: State of Occurrence
2- Safety data Analysis (root-cause analysis, trends, etc.)
3- Main safety risks
4- Safety Recommendations
--------------------
Regional Aviation Safety Group – Middle East (RASG-MID) Eight Edition, xxx 2019 This document is disseminated under the sponsorship of the Regional Aviation Safety Group – Middle East (RASG-MID) in the interest of information exchange. The RASG-MID assumes no liability for its contents or use thereof.
ASRG/1-WP/4 Appendix C
- 1 -
Contents 1. Foreword ...................................................................................................................................... - 3 -
2. Executive Summary ...................................................................................................................... - 3 -
3. Traffic Volumes ............................................................................................................................ - 4 -
4. Reactive Safety Information ......................................................................................................... - 6 -
4.1 Safety Risk Assessment Methodology ...................................................................................... - 6 -
4.2 ICAO Data ................................................................................................................................ - 7 -
4.2.1 MID State of Occurrence ...................................................................................................... - 8 -
4.2.2 MID State of Registry and Operator ................................................................................... - 13 -
4.2.3 ICAO In-depth Analysis of Accidents ................................................................................. - 19 -
4.3 ................................................................................................. Error! Bookmark not defined.
4.4 MID Region Safety Performance - Safety Indicators-Reactive ............................................... - 22 -
5. Proactive Safety Information ..................................................................................................... - 23 -
5.1 ICAO USOAP-CMA .................................................................................................................. - 23 -
5.2 IATA IOSA and ISAGO ............................................................................................................ - 25 -
5.2.1 IATA Operational Safety Audit (IOSA) ........................................ Error! Bookmark not defined.
5.2.2 IATA Safety Audit for Ground Operations (ISAGO) ............................................................ - 27 -
5.3 Incidents Reported by Airlines - STEADES Data ...................................................................... - 27 -
5.4 Region Safety Performance - Safety Indicators-Proactive ...................................................... - 29 -
6. Predictive Safety Information .................................................................................................... - 30 -
6.1 State Safety Programme (SSP) ............................................................................................... - 30 -
6.2 IATA Safety Data .................................................................................................................... - 32 -
6.3 MID Region Safety Performance – Safety Indicators – Predictive .......................................... - 32 -
7. Overall Analysis .......................................................................................................................... - 34 -
7.1 Identification of Focus Areas for MID Region ......................................................................... - 34 -
7.2 Identification of emerging risks for MID Region .................................................................... - 36 -
8. Final Conclusions ....................................................................................................................... - 37 -
- 2 -
Appendix A: List of Acronyms ................................................................................................................ - 38 -
- 3 -
1. Foreword The Regional Aviation Safety Group-Middle East (RASG-MID) was established in September 2011 to develop an integrated, data driven strategy and implement a work program that supports a regional performance framework for the management of safety. RASG-MID supports the implementation of the ICAO Global Aviation Safety Plan (GASP) and the achievement of the Safety Targets in the MID Region Safety Strategy. The RASG-MID membership includes representatives from ICAO, MID States, and international organizations. RASG-MID consists of four main teams; the Annual Safety Report Group (ASRG), the Aerodrome Safety planning and Implementation Group (ASPIG), the Safety Enhancement Initiative Group (SEIG), the Accident and Incident Investigation Group (AIIG), and the Aerodrome (APIG). The Annual Safety Report Team (ASRG) is in charge of collecting and analysing safety information. The Team is also responsible for the identification of the safety focus areas and the production of the RASG-MID Annual Safety Report (ASR). The RASG-MID Annual Safety Report is a timely, unbiased and transparent source of safety related information essential for all aviation stakeholders interested in having a tool to enable sound decision-making on safety related matters.
2. Executive Summary
Over the last five years, the global scheduled commercial international operations accounted for approximately 37.7 million departures in 2018, compared to 31.9 million departures in 2014. The MID Region showed a stable growth in traffic volumes. Total scheduled commercial departures in 2018 accounted approximately for 1.4 million departures compared to 1.15 million departures in 2014. In terms of aircraft accident, the MID Region had an accident rate of 2.3 accidents per million departures in 2018, which increased compared to 1.45 in 2017. The MID Region accident rate in 2018 is still below the global accident rate which is 2.6 accidents per million departures. However, the 5-year average accident rate for 2014-2018 is 2.6, which is almost similar to the global average rate (2.58) for the same period. The MID Region had a fatal accident rate of 0.71 accidents per million departures in 2018, which increased compared to the previous year (2017). However, the 5-year average fatal accident rate for 2014-2018 is 0.78, which is slightly above the global average rate (0.45) for the same period. The MID Region had no fatal accident in 2017. However, four fatal accidents occurred in 2014, 2015, 2016, and 2018. The 2014 accident caused 38 fatalities, 224 fatalities were registered in 2015, 1 fatality in 2016, and the year 2018 caused 66 fatalities. Based on the analyses of all accidents, serious incidents, and incidents data, it is concluded that the Focus Areas for the MID Region are: 1. Loss of Control Inflight- (LOC-I); 2. Runway Safety (RS)- (mainly RE and ARC during landing); 3. Controlled Flight Into Terrain- (CFIT); and 4. Mid Air Collision- (MAC)
- 4 -
New emerging risks have been identified, as follows: 1. Security risks with impact on safety-SEC; 2. Fire/Smoke-non impact- (F-NI); 3. Runway Incursion- (RI); 4. Birdstrike- (BIRD); and 5. Wake Turbulence (Vortex). The regional average overall Effective Implementation (EI) in the MID Region (13 out of 15 States have been audited) is 75.23 %, which is above the world average 68.53% (as of 25 Sep 2019). Three (3) States are currently below EI 60%. The EI by Area (e.g. Operations, Airworthiness) shows that all areas are above 60% EI, which reflect the improvement in the oversight capabilities particularly in the area of ANS and AGA. With respect to the Critical Elements (CEs), CE4 (Qualified technical personnel) improved and is above 60% (61.71%) EI, whereas CE8 (resolution of safety issues) is the only one below EI 60% (59. 47%). Implementation of SSP is one of the main challenges faced by States in the MID Region. The RASG-MID addresses the improvement of SSP implementation in the MID Region as one of the top Safety Enhancement Initiatives (SEIs). Currently, States in the MID Region could not reach to full implementation of the SSP framework. Common challenges/difficulties have been identified based on the States feedback and recommendations for the way forward were provided in this regard. Several activities took place to support the implementation of SSP/SMS, including the new ICAO Safety Management Training Programme (SMTP), SSP implementation Workshops, and meetings in order to address the challenges and difficulties, as well as sharing of experiences and best practices.
3. Traffic Volumes
Global Traffic The global scheduled commercial international operations accounted for approximately 37.7 million departures in 2018, compared to 31.9 million departures in 2014.
Graph 1: Global Traffic Volume (Source iSTARSs of 23 Sep 2019)
MID Traffic
31.932.9
34.936.3
37.7
2014 2015 2016 2017 2018
Global Traffic Million of Scheduled Commercial Departures
- 5 -
The MID Region shows a stable growth in traffic volumes. Total scheduled commercial departures in 2018 accounted approximately for 1.4 million departures compared to 1.15 million departures in 2015.
Graph 2: MID Traffic Growth (Source iSTARSs of 23 Sep 2019)
1.15 1.22 1.3 1.37 1.4
2014 2015 2016 2017 2018
MID Traffic Million of Scheduled Commercial Departures
- 6 -
4. Reactive Safety Information
4.1 Safety Risk Assessment Methodology In order to facilitate the identification and prioritization of the main Regional Risk Category Focus Areas (FAs), accidents and serious incidents are categorized in terms of frequency and severity. The severity assessment is based on the fatalities, injuries and damage to aircraft, property and equipment. (For Frequency rating: 1 is the most frequent and 6 is the least frequent. For Severity: 1 is the most severe and 4 is the least severe) The MID ASRT/2 meeting (Cairo, Egypt, 4-5 February 2018) agreed to the following improvements to the methodology used for risk assessment:
a) improvement of the current risk matrix used for the identification of focus areas (four (4) levels of severity instead of three (3)), as follows:
improvement of the current risk matrix used for the identification of focus areas (four (4) levels of severity instead of three (3)), The level of severity is categorized as follows:
1) Catastrophic: multiple deaths; serious damage to aircraft/equipment (destroyed) 2) Major: serious injury/fatalities; major aircraft/equipment damage 3) Minor: little consequences (minor injuries, minor damage to aircraft); 4) No potential damage or injury
Frequency Severity
1 2 3 4 5 6
1 1 2 3 4 5 6
2 2 4 6 8 10 12
3 3 6 9 12 15 18
4 4 8 12 16 20 24
b) Adoption of the “feared consequences” of the risk portfolio of DGAC France:
- 7 -
The Table below shows that each identified Undesirable event/safety issue is linked to the potential accident outcome.
4.2 ICAO Data ICAO’s primary indicator of safety in the global air transport sector is the accident rate based on scheduled commercial operations involving aircraft having a Maximum Take-off Weight (MTOW) above 5700 kg. Exposure data is comprised of scheduled commercial operations that involve the transportation of
Nb Identfication of Undesirable Event
CFIT LOC-I MAC Ground Collision
RE
Damage to aircraft
or injury inflight
Damage to aircraft or /injury on
ground
UE.1Unstabilised or non-compliant approach
X X X X
UE.2Abnormal airplane attitude (Roll, pitch, speed…) X X
UE.3
Events relating to aerodrome conditions (Runway surafce condition and aerological parameters) X X X X
UE.4
En-route encounter of dangerous weather phenomena (Thunderstorm, turbulence, Icing)
X # X X
UE.5 Misuse of aircraft system (Weight and Balance, speed track, aircraft config) X X X X X X X
UE.6Event pertaining to works/maintenance operations on or close to a runway # X X X
UE.7 Bad coordination/execution of ground operations (deicing, loading, stowing, line maintenance, etc)
X X X X X
UE.8 Runway/taxiway incursion X X X
UE.9Loss of separation in flight/ and/or airspace infringement /level bust X X X X
UE.10 Wildlife hazard, including bird strike X X X X
UE.11Ground-onboard interface failure (Misunderstanding, unsuitability of transmitted information,etc)
X X X X X X X
UE.12 Aircraft maintenance event X X # X X X
UE-13 Fire/Smoke inflight # X X X
UE-14Aircraft system failure resulting in flight management disturbance X X # X X X
UE-15 Loss of cabin pressure X # X
UE-16 Aircraft damage due to FOD X X X X
Potential Accident outcome
- 8 -
passengers, cargo and mail for remuneration or hire, and is a preliminary estimate solely for the calculation of the accident rates. ICAO iSTARS (ADREP et al and API Data service.) applications contain an aggregation of different accident and incident data sources including ADREP, Aviation Safety Network and Aviation Herald to provide official ICAO accident statistics used for the development of the ICAO Safety Reports. Note: The accident and serious incidents data presented here is the official ICAO accident statistics, used for the development of the ICAO safety reports. The data is based on scheduled commercial operations involving aircraft having a Maximum Take-off Weight (MTOW) above 5700 kg (validated or under validation by ICAO). The main part of this Section provides analysis of the accidents that occurred in the MID Region (State of Occurrence) for the period (2014-2018), which is used for monitoring the progress of achieving the Safety Targets in the MID Region Safety Strategy. In addition, it provides data analysis regarding accidents and serious incidents of aircraft registered in the MID Region (State of Registry) as well as for the MID air operators (State of the Operator) using the same criteria mentioned above. It is to be highlighted that the State of registry and State of operator Section focuses mainly on counts and percent distribution (no rates). 4.2.1 MID State of Occurrence Accidents Rates and Fatalities The Graph 3 shows that the MID Region had an accident rate of 2.3 accidents per million departures in 2018, which increased compared to the previous year (2017). However, the 5-year average accident rate for 2014-2018 is 2.6, which is almost similar to the global average rate (2.58) for the same period. The Graph 4 shows that 15 accidents occurred in the MID Region during the period (2014-2018), whereas (450) accidents occurred globally.
Graph 3: Global Accident Rate Vs MID Accident Rate (Source iSATRS as of 24 Sep 2019)
32.9
2.12.4
2.6
4.3
2.52.3
1.52.3
0
5
2014 2015 2016 2017 2018
Acci
dent
s per
mill
. dep
.
Accident RateScheduled Commercial above 5700 kg
Accident Rate - World Accident Rate - MID
- 9 -
Graph 4: Number of MID Accidents Vs. Number of Global Accidents Per Year (Source: iSTARS as of 24 sep 2019) The Graph 5 shows that the MID Region had a fatal accident rate of 0.71 accidents per million departures in 2018, which increased compared to the previous year (2017). However, the 5-year average fatal accident rate for 2014-2018 is 0.78, which is slightly above the global average rate (0.45) for the same period. The MID Region had no fatal accidents in 2017. However, four fatal accidents occurred in 2014, 2015, 2016, and 2018. The 2014 accident caused 38 fatalities, 224 fatalities were registered in 2015, 1 fatality in 2016, and the year 2018 caused 66 fatalities as shown in Graph 6.
Graph 5: Global Fatal Accident Rate Vs MID Fatal Accident Rate (Source: iSTARS as of 24 Sep 2019)
97 9275
8898
5 3 2 2 30
50
100
2014 2015 2016 2017 2018Num
ber o
f Acc
iden
ts
AccidentsScheduled Commercial above 5700 kg
Accidents - World Accidents - MID
0.21 0.18 0.26
1.32
0.29
0.86 0.81
1.54
0.71
0
2
2014 2015 2016 2017 2018Fata
l Acc
iden
ts p
er m
ill. d
ep.
Fatal Accident RateScheduled Commercial above 5700 kg
Fatal Accident Rate - World Fatal Accident Rate - MID
- 10 -
Graph 6: Number of MID Fatalities Vs. Global Fatalities (Source: iSTARS as of 24 Sep 2019) The Graph 7 shows that 15 accidents occurred during the period of 2014-2018 and no fatal accident occurred during the year of 2017. Four fatal accidents occurred respectively during 2014, 2015, 2016, and 2018.
Graph 7: Number of Fatal Accidents Vs Non-Fatal Accidents Per Year (2014-2018) (Source: iSTARS as of 24 Sep 2019)
Occurrence Category The Graph 8 indicates that during the period (2014-2018), the CFIT accidents has not been reported. However, the Loss of control-inflight (LOC-I), the engine failure/malfunction (SCF-PP), Non-Power plant (SCF-NP), runway excursion (RE), abnormal runway contact (ARC), and security (SEC) events represent the main areas of concern.
911
474
182 50
514
38224
1 0 660
500
1,000
2014 2015 2016 2017 2018
Num
ber o
f Fat
aliti
es
FatallitiesScheduled Commercial above 5700 kg
Fatalities - World Fatalities - MID
1
1
1
0
1
4
2
1
2
2
2 0 1 4
2 0 1 5
2 0 1 6
2 0 1 7
2 0 1 8
Sum of Fatal Accidents
Sum of Non-Fatal Accidents
- 11 -
Graph 8: Distribution of Occurrence Category Per Year (2014-2018) (Source: iSTARS as of 24 Sep 2019)
Phase of Flight The Graph 9 shows that the majority of accidents occurred during landing phase of flight. The majority of Abnormal Runway Contact (ARC) and Runway Excursion (RE) events took place during landing flight phase. However, one abnormal runway contact accident took place during landing (Go-around) flight phase. The engine failure/malfunction events occurred during take-off and En-route flight phases. The Loss of Control-Inflight (LOC-I) occurred during En-route flight phase.
Graph 9: Distribution of Occurrence Category Per Phase of Flight (2013-2017) (Source: iSTARS as of 24 Sep 2019)
RE
RE
ARC
ARC
ARC
SCF-PP
SCF-PP
SCF-NP
TURB
GCOL OTH
F-NI
SEC
LOC-I
2 0 1 4
2 0 1 5
2 0 1 6
2 0 1 7
2 0 1 8
Standing
Taxi
Taxi
Take-off En-route
En-route
En-route
Approach
Landing
Landing
Landing
0 1 2 3 4 5
RE
ARC
SCF-PP
SCF-NP
GCOL
OTH
SEC
TURB
F-NI
LOC-I
- 12 -
The Graph 10 shows that most of the accidents categories experienced during the 2014-2018 were the abnormal runway contact (ARC) and Runway Excursion (RE), followed by system component failures.
Graph 10: Occurrence Category Distribution as Percentage Per Accident ( Source: iSTARSas of 24 Sep 2019) The Graph 11 shows that the fatalities for the period 2014-2018 were mainly associated to the following Occurrence Categories: Security (SEC), Loss of Control-Inflight (LOC-I), and engine failure/malfunction (SCF-PP).
Graph 11: Fatalities Distribution as Percentage by Occurrence Category (2014-2018) (Source: Istars as of 24 Sep 2019) Taking a more in-depth look at the fatal accidents and accidents for the MID Region (State of occurrence) for the period 2014-2018, the following observations are made:
a) In terms of fatality, the top three fatal accidents categories in the MID Region are: 1. Security – SEC; 2. Loss of control-Inflight- (LOC-I); and 3. System Component Failure- Power Plant - (SCF-PP )
26.67%
13.33% 13.33%
6.67% 6.67% 6.67% 6.67% 6.67% 6.67% 6.67%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
ARC RE SCF-PP SCF-NP GCOL SEC LOC-I F-NI TURB OTH
68.09%
20.06%
11.55% 0.30% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
SEC LOC-I SCF-PP ARC GCOL TURB F-NI RE SCF-NP OTH
- 13 -
b) In terms of frequency, the most frequent accidents categories in the MID Region (State of occurrence) are:
1. Runway Safety (RS) – including (RE, ARC, and GCOL); 2. System Component Failure – Power Plant (SCF-PP); 3. System Component Failure– Non-Power Plant (SCF-NP); 4. Fire/Smoke (F-NI); and 5. Turbulence Encounter (TURB)
Identification of the main Risk Areas based on the analysis of accident data related to the State of Occurrence (2014-2018) To facilitate the identification of the safety priority areas; the safety risk assessment methodology is applied. Applying the “feared consequences” of the risk portfolio of DGAC France, the system component failure- Power Plant fatal accident has led to the potential outcome of Loss of control inflight (LOC-I), consequently, the SCF-PP was considered under the risk of loss of control-inflight. In addition, two fatal accident had led to the LOC-I.
Main Risk Area Frequency Severity Risk Level Loss of Control-Inflight (LOC-I) 2 1 2 Runway Safety (RS) 1 3 3 Security (SEC) 3 1 3
Therefore, the safety risk areas according to the State of occurrence’s accidents data are
a) Loss Of Control -Inflight – (LOC-I); b) Runway Safety (RS): Runway Excursion (RE) and Abnormal Runway Contact (ARC) during landing;
and c) Security related-(SEC).
4.2.2 MID State of Registry and Operator
Accident Data Analysis
The Graph 12 shows the change in the number of Fatal Accidents and non-Fatal Accidents over the last five years involving MID State of registry and State of operator airplanes. The Graph 12 also indicates that two fatal accidents were recorded during 2018, which indicated an increased number of fatal accidents in 2018 compared to the previous years. Three fatal accidents occurred in 2016 involving MID Operators and one in the year of 2014. In terms of fatalities, the Graph 13 shows that the four fatal accidents, which occurred in 2014 and 2016, resulted in 234 fatalities.
- 14 -
Graph 12: Number of Fatal and Non-Fatal Accidents per Year (2014-2018) (Source: iSTARS as of 24 Sep 2019)
Graph 13: Number of Fatalities per Year (2014-2018) (Source: iSTARS as of 24 Sep 2019)
Phase of Flight The Graph 14 shows that the majority of accidents related to Runway Excursion (RE), Abnormal Runway Contact (ARC), and system component failure- Non-power plant (SCF-NP) occurrence categories took place during landing flight phase. It was also noted that the engine failure/malfunction-related accident occurred during take-off (initial climb) and en-route phases of flight. Regarding, Loss of Control Inflight (LOC-I), it took place during en-route and approach (Go-around) flight phase.
Graph 14: Distribution of the Number of Accidents Category per Phase of Flight (2014-2018) (Source: iSTARS as of 24 Sep
2019)
1
4
3
2
2
1
3
2
0 1 2 3 4 5 6 7
2014
2015
2016
2017
2018
Sum of Non-Fatal Accident
Sum of Fatal Accident
38
0
129
0
67
0 20 40 60 80 100 120 140
2014
2015
2016
2017
2018
Standing
TaxiTaxi
Take-off
Take-off
En route
EnrouteEn route
En route
Approach
Approach
LandingLanding
Landing
0 0.5 1 1.5 2 2.5 3
REARC
SCF-PPSCF-NP
GCOLOTHUNK
TURBRAMPLOC-ICTOL
- 15 -
Occurrence Category The Graph 15 shows the percentage of fatalities associated with the accident Categories for the period 2014-2018: Loss of Control in flight (LOC-I), Unknown (UKN), engine failure/malfunction (SCF-PP), Abnormal Runway Contact (ARC) and RAMP.
Graph 15: Fatalities Distribution as Percentage by Occurrence Category (2014-2018) (Source: iSTARS as of 24 Sep 2019)
The Graph 16 shows that most of the accidents categories experienced during the period 2014 – 2018 was Turbulence (TURB), followed by ARC, SCF-PP, LOC-I, GCOL and RAMP. However, considering that RE, GCOL, RAMP, CTOL and ARC are all considered part of the Runway Safety (RS) Risk Category, RS is still the most frequent. Two LOC-I occurrence had resulted in fatalities. Regarding “Unknown” occurrence category, the causal factors of the accident are still under investigation and thus the occurrence category could not be defined at this stage.
Graph 16: Accident Distribution as Percentage per Occurrence Category (2014-2018) (Source: iSTARS as of 24 Sep 2019)
54.70%
28.21%
16.24% 0.43% 0.43% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
LOC-I UNK SCF-PP ARC RAMP CTOL OTH TURB RE GCOL SCF-NP
16.67%
11.11% 11.11% 11.11% 11.11% 11.11%
5.56% 5.56% 5.56% 5.56% 5.56%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
TURB ARC SCF-PP GCOL LOC-I RAMP CTOL RE UNK SCF-NP OTH
- 16 -
During 2014-2018, no CFIT accident occurred. However, two LOC-I accidents had taken place during the period of 2016 and 2018. Engine failure/malfunction (SCF-PP), Runway Excursion (RE), Abnormal Runway Contact (ARC), and Turbulence (TURB) events were registered and are still prevailing.
Graph 17: Accident Category Distribution per Year (Source: iSTARS as of 24 Sep 2019)
Taking a more in-depth look at the fatal and non-fatal accidents for the MID Region (State of registry and State of operator) for the period 2014-2018, the following is to be highlighted:
a) In terms of fatality, the fatal accidents categories in the MID Region for the period 2014 – 2018 are: 1. Loss Of Control- In-flight (LOC-I); 2. Unknown (UNK); 3. System Component Failure – Power Plant (SCF-PP); and 4. Runway Safety – Abnormal Runway Contact (ARC).
b) In terms of frequency, the most frequent accidents categories in the MID Region (State of registry and State of occurrence) for the period 2014 – 2018 are: 1. Runway Safety (RS) – (RE, ARC, GCOL, RAMP, and CTOL); 2. Turbulence encounter – (TURB); 3. System Component Failure-Power Plant (SCF-PP); and 4. System Component Failure- non-power plan (SCF-NP).
Identification of the main Risk Areas based on the analysis of safety data related to the State of registry and State of operator (2014-2018) To facilitate the identification of the safety priority areas; the safety risk assessment methodology is applied. Applying of the “feared consequences” of the risk portfolio of DGAC France, the system component failure- Power Plant fatal accident has led to the potential outcome of Loss of control inflight,
RE ARC
ARC
SCF-PP
1
TURB
TURB
GCOL
GCOL
OTH
UNK
CTOL
LOC-I
LOC-I RAMP
0 1 2 3 4 5 6 7
2014
2015
2016
2017
2018
- 17 -
consequently, the SCF-PP was considered under the risk of loss of control-inflight. Therefore, the safety risk areas according to the State of registry and operator accidents data are:
Main Risk Area Frequency Severity Risk Level Loss of Control-Inflight (LOC-I) 2 1 2 Runway Safety (RS) 1 3 3 Turbulence (TURB) 2 5 10 System Component Failure- non power plan (SCF-NP)
4 4 16
a) Runway Safety (RS): Runway Excursion (RE) and Abnormal Runway Contact (ARC) during
landing; and b) Loss of Control-Inflight (LOC-I).
Serious Incidents Data Analysis The Graph 18 shows that there were no reported serious incidents during the year of 2017 compared to the previous years.
Graph 18: Number of Serious Incidents per Year (2014-2018)
6
9
12
0
18
0 2 4 6 8 10 12 14 16 18 20
2014
2015
2016
2017
2018
- 18 -
Occurrence Category The Graph 19 shows that most of the serious incident categories experienced during the period 2014 - 2018 were the system component failures (PP and NP combined), followed by the fire/smoke; Runway Excursion and abnormal runway Contact categories. The near midair collision events have been recorded, but took place outside the MID Region airspace.
Graph 19: Serious Incidents Distribution as Percentage per Occurrence Category (2014-2018)
Taking a more in-depth look at the serious incidents for the MID Region (State of registry and State of operator) for the period 2014-2018, the following is to be highlighted:
a) In terms of frequency, the most frequent serious incidents categories in the MID Region are:
1. Runway Safety (RS) – (RE, ARC, GCOL, RAMP, CTOL, BIRD, RI); 2. System Component Failure (SCF)- (SCF-PP and SCF-NP); 3. Fire/smoke- (FN-I); 4. Medical (MED); 5. Near Mid Air Collision (NMAC); 6. Turbulence (TURB); 7. Fuel; and 8. ICE.
Total number of serious incidents provided by the MID States for the period 2015-2018. The data shows that there was a significant increase on the number of NMAC Occurrences. The number of serious incidents data shared by the MID States have been considered and included in the analysis to shed light and identify the potential safety concerns in the MID region. However further data analysis should be provided by the MID States for an in-depth analysis.
23.21%
12.50%12.50%
10.71%10.71%
5.36%3.57% 3.57% 3.57% 1.79% 1.79% 1.79% 1.79% 1.79% 1.79% 1.79% 1.79%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
- 19 -
Graph 20: Number of Serious Incidents Distribution Per Year (2015-2018)
Taking a more in-depth look at the serious incidents reported by the MID Region for the period 2015-2018, the following is to be highlighted:
b) In terms of frequency, the most frequent serious incidents categories in the MID Region are:
1. Near Mid Air Collision (NMAC); 2. System Component Failure (SCF)- (SCF-NP); and 3. Runway incursion- (RI)
4.2.3 ICAO In-depth Analysis of Accidents
A. Runway Excursions and Abnormal Runway Contact: During 2014-2018, Runway Excursions and abnormal runway contact accidents and serious incidents mainly occurred in the landing phase of flight and counted for approximately 1% of fatality. This focus area covers the risk of runway excursions, including the direct precursors such as hard landings, high speed landing, landings following an un-stabilized approach. The MID Region continued improvement in runway safety, which is one of the industry’s principal risk areas.
Root Cause Analysis
1. Latent Conditions: i. Ineffective safety management system
ii. Incomplete/inefficient operator SOP iii. Deficient flight crew training iv. Regulatory oversight
21
12
1615
67
6 6
3 1 3 35
24
21 15
2 11 1 10
5
10
15
20
25
2015 2016 2017 2018
Sum of NMAC
Sum of SCF-NP
Sum of RI
Sum of SCF-PP
Sum of F-NI
Sum of BIRD
Sum of ARC
Sum of CFIT
Sum of RE
- 20 -
2. Threat: i. Decision to make a landing on short runway with tailwind.
ii. Poor judgment and continued landing after an un-stabilized approach iii. Improper calculating of landing speed without focusing on the tailwind component iv. Technical failures Pilot information v. Contaminated runways
vi. Airport facilities including poor runway paintings/markings vii. Meteorology
3. Errors:
i. Timely crew decisions (very low-level go-arounds) ii. Failed to go around after un-stabilized approach
iii. SOP Manual not updated and maximum tailwind not mentioned iv. Manual handling/flight controls v. Contaminated runways
4. Contributing factors:
i. Anti-skid failures of landing gear causing prolong landing distance. ii. Instantaneous variable wind condition on aerodrome traffic pattern.
iii. Late activation of airbrakes and spoilers (especially airbrakes) with tailwind cause to increase the landing roll distance.
Some of the Precursors, which could Lead to Runway Excursion
1. Precursors for aircraft overrunning the end of the runway on landing (landing overrun) Precursors could include: Long landing / high across threshold / extended flare / floating, incorrect performance calculation, ineffective use of stopping devices / time to apply reverse thrust or braking / inappropriate use of auto brake setting, weather related / runway condition / aquaplaning, unsterilized approach, tailwind landing.
2. Precursors for aircraft veering off the side of the runway during landing (landing veer-off)
Precursors could include: Crosswind and wet /contaminated runway, hard landing / inappropriate use of stopping devices / asymmetric braking or reverse thrust, inappropriate use of nose wheel steering.
B. SCF-PP: Engine Failure or malfunction of an aircraft system or component. The engine
failure/malfunction contributed to the accidents and serious incidents and counted for 16% of fatalities. The majority of SCF-PP accidents and serious incidents between 2014 and 2018 occurred mainly during take-off and en-route phase of flight, with one fatal accident involving turboprop aircraft.
Root Cause Analysis
1. Latent Conditions: i. Regulatory oversight
ii. Deficient maintenance standard operating procedures iii. Ineffective safety management system iv. Insufficient resource availability v. Deficiencies in the evaluation to monitor changes
- 21 -
2. Threats: i. Improper Airworthiness Directive implementation and Control
ii. Poor maintenance and errors related to aircraft dispatch or release iii. Lack of information sharing and support from the State of manufacturer iv. Embargo on aircraft equipment/Spare parts acquisition v. Incorrect or incomplete aircraft performance limitations verification
vi. Errors related to the Aircraft Flight Maintenance adherence vii. Extensive/uncontained engine failure
viii. Incorrect/Unclear aircraft maintenance manual
3. Errors: i. Crew inadequate aircraft handling
ii. Crew SOP Adherence / SOP Cross-verification iii. Improper weight and balance calculations
4. Contributory Factors
i. CAMOs’ and AMO organization’s responsibilities and communication issue ii. Non-compliance with the regulator operational requirements
iii. Ineffective monitoring in operators line maintenance iv. Inadequate monitoring in operations, training and technical divisions
C. Loss of Control-Inflight: During 2014-2018 Aircraft upset or loss of control only contributed to one
accidents but counted for around 55% of fatalities. During the years 2016 and 2018, the LOC-I occurred during go around (GOA) and en-route phases of flight.
Root Cause Types The below root-cause analysis is based mainly on industry’s analysis of the LOC-I accidents:
1. Latent Conditions: i. Inadequate safety management system including the use of the FDM data
ii. Regulatory oversight iii. Incomplete/Inefficient Flight operations
2. Threats: i. Inappropriate Flight Crew Automation training
ii. Type-rating related issues on complex and highly automated aircraft iii. Contained engine/power plant malfunction iv. Severe turbulence, Thunderstorms, wind shear/Gusty wind v. Poor visibility/IMC conditions
vi. Spatial disorientation/Somatogravic illusion vii. Flt Crew misdiagnose the problem leading to the application of an incorrect recovery procedure
viii. Lack of exposure to the required maneuvers during normal line flying operations ix. Limitations in simulator fidelity could lead to pilots not having the manual flying skills required to
recover from some loss of control scenarios.
3. Errors: i. Inappropriate/Incorrect use of Automation by flight crew
ii. Inadequate flight crew monitoring skills/awareness or communication iii. Flt Crew mishandling of manual flight path and/or speed control iv. Abnormal checklist v. Incorrect recovery technique by flight crew when their aircraft has become fully stalled
- 22 -
4. Contributory Factors: i. Unnecessary weather penetration
ii. Operation outside aircraft limitations iii. Unstable approach iv. Vertical/lateral speed deviation
5. Direct Precursors to a Loss of Control Event:
i. Deviation from flight path ii. Abnormal airspeed or triggering of stall protections
4.4 MID Region Safety Performance - Safety Indicators-Reactive
Average
2014-2018
2018
Safety Indicator Safety Target MID Global MID Global
Number of accidents per million departures
Reduce/Maintain the regional average rate of accidents to be in line with the global average rate by 2016 2.58 2.6 2.3 2.6
Number of fatal accidents per million departures
Reduce/Maintain the regional average rate of fatal accidents to be in line with the global average rate by 2016 0.78 0.45 0.71 0.29
Number of Runway Safety related accidents per million departures
Reduce/Maintain the regional average rate of Runway Safety related accidents to be below the global average rate by 2016 0.82 1.23 0 1.24
Reduce/Maintain the Runway Safety related accidents to be less than 1 accident per million departures by 2016 1.54
Number of LOC-I related accidents per million departures
Reduce/Maintain the regional average rate of LOC-I related accidents to be below the global rate by 2016.
0.14 0.08 0.7 0.13
Number of CFIT related accidents per million departures
Reduce/Maintain the regional average rate of CFIT related accidents to be below the global rate by 2016. 0 0.01 0 0.02
- 23 -
5. Proactive Safety Information A mature safety management system requires the integration of reactive, proactive and predictive safety data. This section of the Annual Safety Report focuses on proactive safety data analysis to identify additional focus areas that form the basis for the development of SEIs and DIPs for Emerging Risks under RASG-MID.
5.1 ICAO USOAP-CMA The regional average overall Effective Implementation (EI) in the MID Region (13 out of 15 States have been audited) is 75.23 %, which is above the world average 68.53% (as of 25 Sep 2019). Three (3) States are currently below EI 60%. Currently, 77% of the audited States achieved the target of 60% EI, as suggested by the Global Aviation Safety Plan (GASP) and the MID Region Safety Strategy.
Effective Implementation (EI)
Source: ICAO USOAP CMA On Line Framework (OLF), as of 25 Sep 2019 The EI by Area (e.g. Operations, Airworthiness) shows that all areas are above 60% EI, which reflect the improvement in the oversight capabilities particularly in the area of ANS and AGA. With respect to the Critical Elements (CEs), CE4 (Qualified technical personnel) improved and is above 60% (61.71%) EI, whereas CE8 (resolution of safety issues) is the only one below EI 60% (59. 47%) EI.
EI by Area EI by Critical Element
Source: ICAO iSTARS, as of 25 Sep 2019
29.32%
54.98% 57.76%
68.46%75.24% 78.67% 81.59% 83.65% 84.18% 84.38%
89.61% 91.16%98.91%
0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
100.00%
Effective Implementation (EI)
- 24 -
Incident data provided by the MID States for the period (2015-2017)
The graph below shows that the number of Wake Turbulence incidents reported is the highest one, followed by system component system-non-power plant and airborne conflict incidents (near midair collision). For an in-depth analysis and to identify the underlying safety issues, MID States should provide further data analysis in order to come out with strategic initiatives and mitigations. In addition, the year of 2018 showed an increase in incidents reporting.
Graph 21: Total number of incidents provided by the MID States for the period 2015-2018
- 25 -
5.2 IATA Operational Safety Audit (IOSA) There are currently 430 airlines on the IOSA Registry of which 142 are non-IATA Members. Over the next few years, IOSA will undergo a digital transformation that will enable IOSA airlines to compare and benchmark their performance. In the long run, the digital transformation will help to focus auditing on areas with the highest level of safety risk. IOSA is an internationally recognized and accepted evaluation system designed to assess the operational management and control systems of an airline. It is worth mentioning that IOSA registered airlines outperform non-IOSA airlines in MENA. The accident rate among non‐IOSA registered operators for the period 2014‐2018, was above MENA IOSA registered airlines average by an average of 3.79.
The accident rate for IOSA carriers in 2018 was more than 2 times lower than the rate for non-IOSA carriers.
- 26 -
The IOSA audit results analysis captured under this section cover the period January-December 2018. A summary of the IOSA audit findings is as follows: 1. 23 audits were performed in the MENA Region with an average of 12.5 findings per audit. 2. Findings were mainly in the areas of Maintenance (MNT), Flight Operations (FLT), Organization Management (ORG), Ground Handling Operations (GRH), and Cabin Safety (CAB). Below chart demonstrates the percentage of findings per area:
- 27 -
5.3 IATA Safety Audit for Ground Operations (ISAGO) The ISAGO new operational audit model has been developed in consultation with stakeholders. The program is managed and administered by IATA. The ISAGO new operational audit model implemented in January 2018 have made a significant difference. Ground service providers are experiencing audits that get to the detail of their management and operational processes. The total audits performed in 2018 are 254 of which 20 performed in MENA, 20 with an average of 19 findings raised per audit
5.4 Incidents Reported by Airlines - STEADES Data 5.4.1 Bird strikes Analysis:
The analysis is conducted on Air Safety Reports (ASR) and Cabin Safety Reports (CSR) held in IATA’s Safety Trend Evaluation, Analysis & Data Exchange System (STEADES) database. The STEADES database is comprised of de-identified safety incident reports from over 210 participating airlines throughout the world, with an annual reporting rate now exceeding 200,000 reports/year. The STEADES database incorporates a number of quality control processes that assure analysis results.
The data query resulted in 269 reports. This equals to 0.2245 reports per 1,000 STEADES flights.
- 28 -
95 bird strike events (35%) were reported in United Arab Emirates (UAE), but the rate per 1,000 STEADES flights did not show significance compared to other countries.
85% (210) of bird strikes occurred during Aircraft Approach, Take-off and Landing.
Engine Damage occurred only in 1% (3) of the bird strike reports. One bird strike with engine damage resulted in the aircraft AOG.
- 29 -
5.4 Region Safety Performance - Safety Indicators-Proactive
Safety Indicator Safety Target MID Remark Regional average EI
Increase the regional average EI to be above 70% by 2020
75.23 Target Achieved
Number of MID States with an overall EI over 60%.
11 MID States to have at least 60% EI by 2020
10 States
Number of MID States with an EI score less than 60% for more than 2 areas (LEG, ORG, PEL, OPS, AIR, AIG, ANS and AGA).
Max 3 MID States with an EI score less than 60% for more than 2 areas by 2017
7 States
Number of Significant Safety Concerns
MID States resolve identified Significant Safety Concerns as a matter of urgency and in any case within 12 months from their identification. No significant Safety Concern by 2016.
None
Target Achieved
Use of the IATA Operational Safety Audit (IOSA), to complement safety oversight activities.
a. Maintain at least 60% of eligible MID airlines to be certified IATA-IOSA at all times.
b. All MID States with an EI of at least 60% use the IATA Operational Safety Audit (IOSA) to complement their safety oversight activities, by 2018.
57% (As of Sep 2017)
4 out of 10 States (40%)
Number of certified international aerodrome as a percentage of all international aerodromes in the MID Region.
a. 50% of the international aerodromes certified by 2015.
b. 75% of the international aerodromes certified by 2017.
67%
Number of established Runway Safety Team (RST) at MID International Aerodromes.
50% of the International Aerodromes by 2020. 57%
- 30 -
6. Predictive Safety Information 6.1 MID Region State Safety Programme (SSP) Foundation
A sub-set of 299 Protocol Questions (PQs) out of the 1,047 PQs used to calculate the USOAP Effective Implementation (EI). This sub-set of questions are considered as the foundation for a State Safety Programme (SSP) implementation. A SSP Foundation indicator is calculated, as the percentage of PQs which are either validated by USOAP or submitted as completed* through the corrective action plans(CAP) on the USOAP CMA Online Framework. The average EI for SSP foundation PQs for States in the MID Region is 76, 92%. The SSP foundation EI for MID Region States is shown in the graph below.
Graph 21: Overall SSP foundation for MID Region States (Source: iSTARS as of 25 Sep 2019) The sub-set of PQs are grouped by 17 subjects based on the Annex 19 amendment 1 and the 4th edition of the Safety Management Manual (forthcoming). States with EI above 60% may still have PQs to address which are fundamental for their SSP. Hazard identification and risk assessment is the lowest one with 51%, followed by qualified technical personnel with 55%.
Graph 22: Average EI by Safety Management subjects for States in MID Region (Source: iSTARS as of 30 Oct 2019)
6482
7559
7886
7596
5755
7879
5961
5184
59
0 10 20 30 40 50 60 70 80 90 100
Primary Aviation LegislationSpecific Operating regulations
State authoritiesExemptions
EnforcementState Organizational Structure
State FunctionsDelegationResources
Qualified Technical PersonnelTechnical guidance, tools and provision…
Licensing, certification, authorization and approval obligationsManagement of safety risks
Surveillance obligationsHazard identification and risk assessment
Accident and incident investigationState safety promotion
- 31 -
These PQs can be prioritised and addressed when conducting the SSP gap analysis or while defining the SSP implementation/action plan. States can use the ICAI iSTARS online to perform an SSP Gap Analysis-SMM 4th Edition. This provides an indication of the broad scope of gaps and hence overall workload to be expected. This initial information can be useful to senior management in anticipating the scale of the SSP implementation effort and hence the resources to be allocated/provided. The SSP statistics shown in the graph 22 are high-level information about each Gap analysis project performed by States themselves (Self-reported by the State and not validated by ICAO). SSP implementation progress has been measured for each State using simple milestones as per the entered data. A State having reviewed all Gap analysis Questions (GAQs) has reached level 2. A State having reviewed and defined actions for all GAQs has reached level 3. A State having completed all actions has reached 4. The completion percentage of GAQs in each level is given in graph 23 for States in the MID Region.
Graph 23: SSP Implementation Progress for States in MID Region, Limited to States with EI>=60%- States number: 9 (Source: iSTARS as of 26 Sep 2019) 6.2 MID Region State Safety Programme (SSP) Implementation challenges Implementation of SSP is one of the main challenges faced by the State in the MID Region. The RASG-MID addresses the improvement of SSP implementation in the MID Region as one of the top Safety Enhancement Initiatives (SEIs). Common challenges/difficulties have been identified based on the States’ feedback, as follows:
1. establishment of an initial Acceptable Level of Safety Performance (ALoSP), which necessitates effective reporting system to support collection/analysis of safety data;
2. allocation of resources to enable SSP implementation 3. identification of a designated entity (SSP Accountable Executive and SSP Implementation Team);
and 4. lack of qualified and competent technical personnel to fulfil their duties and responsibilities
regarding SSP implementation. The following actions were recommended to support the SSP implementation:
• continuous update of the SSP Gap Analysis available on iSTARS (13 States completed the Gap Analysis);
• participate in the new ICAO Safety Management Training Programme (SMTP), with the CBT part and the Safety Management for Practitioners Course;
• work with the ICAO Regional Office to make use of available means (e.g. Technical Co-operation Bureau) to provide assistance needed for SSP implementation; and
- 32 -
• identify safety management best practices in coordination with States (champion State to promote best practices among other States) including sharing of technical guidance and tools related to SSP (e.g. advisory circulars, staff instructions);
• establishment of voluntary and mandatory safety reporting systems. The RASG-MID also supported the establishment of the MENA RSOO, with a primary objective to assist member States to develop and implement SSP. The MENA RSOO is still in the establishment process. Several Safety Management Workshops, training courses, and meetings have been organized to support the implementation of SSP/SMS and address the challenges and difficulties, as well as sharing of experiences and best practices. 6.2 IATA Safety Data
IATA’s main database for collecting predictive safety information is Flight Data Exchange (FDX). It is an aggregated de-identified database of FDA/FOQA type events that allows the user to proactively identify safety hazards.
Due to the low levels of participation by the MID Region carriers in FDx program, no useful information could be extracted. 6.3 MID Region Safety Performance – Safety Indicators – Predictive
Safety Indicator Safety Target MID
Number of MID States, having completed the SSP gap analysis on iSTARS.
10 MID States by 2015 10 States
Number of MID States that have developed an SSP implementation plan.
10 MID States by 2015 8 States
Number of MID States with EI>60%, having completed implementation of SSP Phase 1.
All MID States with EI>60% to complete phase 1 by 2016.
3 States
(4 States-partially)
Number of MID States with EI>60%, having completed implementation of SSP Phase 2.
All MID States with EI>60% to complete phase 2 by the end of 2017.
1 State
(6 States-partially)
Number of MID States with EI>60%, having completed implementation of SSP Phase 3.
All MID States with EI>60% to complete phase 3 by the end of 2018.
(7 States-partially)
- 33 -
Number of MID States with EI>60%, having completed implementation of SSP.
All MID States with EI>60% to complete SSP implementation by 2020
None
Number of MID States with EI>60% that have established a process for acceptance of individual service providers’ SMS.
a. 30% of MID States with EI>60% by 2015.
b. 70% of MID States with EI>60% by 2016.
c. 100% of MID States with EI>60% by 2017.
75%
- 34 -
7. Overall Analysis 7.1 Identification of Focus Areas for MID Region The reactive and proactive safety information provided by ICAO, IATA, MID Region States and the “feared consequences” of the risk portfolio of DGAC France were considered for identifying the main risk areas for the MID Region as follow:
Potential Accident Outcome Safety Issues Accident
Severity CFIT LOC-I MAC GCOL RE/ARC Injury or
Damage inflight
Injury or Damage on Ground
Technical Problems with Landing Gear Collapse/not Extended during landing
Major x x
Contained engine Failure/Power Plant Malfunctions
Catastrophic x x x
Flight Planning and Preparation Catastrophic x x x
Fire/Smoke-non impact Catastrophic x x x
Un-stable or non-complaint Approach
Catastrophic x x x x
Convective weather (Turbulence, Hail, Lightning)
Deviation from pitch or roll attitude Catastrophic x x x
Security Risks with impact on safety Catastrophic x
Monitoring of flight parameters and automation modes
Catastrophic x
Tail/Cross wind/Winds hear Catastrophic x x x
Loss of separation in flight/ and or airspace/TCAS RA infringement
Catastrophic x x x
Runway Incursion Catastrophic x x x Maintenance events and technical failures
Catastrophic x x x x x
Contaminated runway/Poor braking action
Major x x
Birdstrike/Engine Bird ingestion Catastrophic x x x x
Wake Vortex Catastrophic x x Handling and execution of Go-arounds
Catastrophic x x x
- 35 -
The table shows that each identified safety issue is linked to the potential accident outcome (s). First, Considering ICAO reactive safety information, the focus areas identified were the Loss of Control-in Flight (LOC-I) and runway safety (RE/ARC). Considering also the reactive and proactive safety information, safety events identified which could lead to the potential accident outcomes of Controlled Flight Into Terrain (CFIT) and Mid Air Collision (MAC) as detailed in the above table of feared consequences” of the risk portfolio of DGAC France. Therefore, the CFIT and MAC were also considered as focus areas due to the potential risk of these type of accidents though the MID States did not experience those accidents during the period 2014-2018. Based on the analyses of reactive and proactive safety information, it is concluded that the Focus Areas for the MID Region are:
1. Loss of Control-In Flight (LOC-I); 2. Runway Safety (RS); mainly (RE and ARC during landing); 3. Controlled Flight Into Terrain (CFIT); and 4. Mid-Air Collision (MAC)
Further information about the potential accident outcomes regarding the focus areas is provided below: Loss of control-inflight (LOC-I) Loss of control usually occurs because the aircraft enters a flight regime that is outside its normal envelope, usually, but not always, at a high rate, thereby introducing an element of surprise for the flight crew involved. Prevention of loss of control is a strategic priority. During 2014-2018 aircraft, upset or loss of control contributed three accidents. It includes uncontrolled collisions with terrain following engines failures after take-off, but also occurrences where the aircraft deviated from the intended flight path or aircraft flight parameters, regardless of whether the flight crew realized the deviation and whether it was possible to recover or not. Runway Excursions (RE): RE is a veer or overrun off the runway surface. RE events can happen during take-off or landing. During the period 2014-2018, Runway Excursions and abnormal runway contact accidents and serious incidents mainly occurred in the landing phase of flight. This includes materialized runway excursions, both high and low speed and occurrences where the flight crew had difficulties maintaining the directional control of the aircraft or of the braking action during landing, where the landing occurred long, fast, off-centred or hard, or where the aircraft had technical problems with the landing gear (not locked, not extended or collapsed) during landing. Mid-Air Collision (MAC) Refers to the potential collision of two aircraft in the air. It includes direct precursors such as separation minima infringements, genuine TCAS resolution advisories or airspace infringements. Although there have been no aero-plane mid-air collision accidents in recent years within the MID States, this key risk area has been raised by some MID States. This is one specific safety issue that is a main priority in this key risk area. However, additional data is needed for further analysis in order to identify the underlying safety issues. Controlled Flight In to Terrain (CFIT) It comprises those situations where the aircraft collides or nearly collides with terrain while the flight crew has control of the aircraft. It also includes occurrences, which are the direct precursors of a fatal outcome, such as descending below weather minima, undue clearance below radar minima, etc. There was no fatal accident involving MID States operators during this period. This key risk area has been raised by some
- 36 -
MID States and in other parts of the world that make it an area of concern. However, additional data is needed for further analysis in order to identify the underlying safety issues. 7.2 Identification of emerging risks for MID Region New emerging risks have been identified, as follows: Regarding the emerging risks mainly identified from ICAO, IATA data, serious incidents and the incidents data provided by the States except the risk of security related which was included under the accident data of the State of occurrence.
1. Security Risks with impact on safety-SEC; 2. Fire/smoke- (non-impact)- (FN-I); 3. Runway incursion (RI); 4. Birdstrike-(BIRD); and 5. Wake Vortex.
Runway incursion (RI) A Runway Incursions refers to the incorrect presence of an aircraft, vehicle or person on an active runway or in its areas of protection. Their accident outcome is runway collisions. While there were no fatal accidents or accidents involving MID States operators in the last years involving runway collision, the risk of the reported occurrence demonstrated to be very real. In addition to this, MID States should provide further data analysis regarding runway incursion in order to identify the root causes and associated safety issues. Fire/Smoke- (non-impact) (FN-I) Uncontrolled fire on board an aircraft, especially when in flight, represents one of the most severe hazards in aviation. In-flight fire can ultimately lead to loss of control-inflight, either because of structural or control system failure, or again because of crew incapacitation. Fire on the ground can take hold rapidly and lead to significant casualties if evacuation and emergency response are not swift enough. Smoke or fumes, whether they are associated with fire or not, can lead to passenger and crew incapacitation and will certainly raise concern and invite a response. Even when they do not give rise to a safety impact, they can give rise to concerns and need to be addressed. While there were no fatal accidents involving MID States operators in the last years involving fires, there have been incidents reported by MID States, which make it an area of concern. Security related (SEC) The impact of security in safety is a real concern and should be considered as a strategic priority. In addition, it should be shared with MID shared with MID States and ICAO MID Office (AVSEC) for further data collection and analysis and come out with strategic initiatives. Birdstrike (BIRD) Their accident outcomes could lead to runway collisions or Loss of control-inflight or runway excursions. While there were no fatal accidents involving MID States air operators in the last years involving birdstrike, there have been huge number of birdstrike occurrences reported by MID States and analysis provided by IATA that make it an area of concern. Thus, MID States should provide further data analysis in order to identify the root causes and associated safety issues.
- 37 -
Wake Vortex Their accident outcomes could lead to Loss of control-inflight. While there were no fatal accidents involving MID States air operators in the last years involving wake turbulence. However, there have been number of wake vortex occurrences reported by MID States which make it an area of concern. Therefore, further attention should be given this safety issue.
8. Final Conclusions Following the analysis of the reactive and proactive safety information provided by ICAO, IATA, and MID Region States for the period 2014 - 2018, it was concluded that the main Focus Areas for the MID Region are:
1. Loss of Control-Inflight (LOC-I); 2. Runway Safety (RS)-(RE and ARC during landing); 3. Controlled Flight Into Terrain- (CFIT); and 4. Mid-Air Collision- (MAC).
The following are identified as Emerging Risks in the MID Region besides the old ones:
1. Security risks with impact on safety- SEC; 2. Fire/Smoke (non-impact)- F-NI; 3. Runway Incursion (RI); 4. Birdstrike- (BIRD); and 5. Wake vortex.
The regional average overall Effective Implementation (EI) in the MID Region (13 out of 15 States have been audited) is 75.23 %, which is above the world average 68.53% (as of 25 Sep 2019). Three (3) States are currently below EI 60%. The EI by Area (e.g. Operations, Airworthiness) shows that all areas are above 60% EI, which reflect the improvement in the oversight capabilities particularly in the area of ANS and AGA. With respect to the Critical Elements (CEs), CE4 (Qualified technical personnel) improved and is above 60% (61.71%) EI, whereas CE8 (resolution of safety issues) is the only one below EI 60% (59. 47%). Implementation of SSP is one of the main challenges faced by the State in the MID Region. The RASG-MID addresses the improvement of SSP implementation in the MID Region as one of the top Safety Enhancement Initiatives (SEIs). Common challenges/difficulties related to SSP implementation include identification of a designated entity, establishment of an initial Acceptable Level of Safety Performance (ALoSP), allocation of resources to enable SSP implementation and lack of qualified and competent technical personnel. It should be highlighted that reporting of incidents is still low in the MID Region (Confidentiality concerns). Moreover, mechanisms for gathering and processing predictive safety information at regional level should be established in order to collect and analyse safety data to proactively identify safety concerns before accidents and/or incidents occur, to develop timely mitigation and prevention measures. It is to be highlighted that the RASG-MID/7 meeting held in Cairo during 15-18 April 2019 endorsed the revised version of the MID Region Safety Strategy. Therefore, in the next MID Annual Safety Report Edition the revised safety indicators and targets will be included.
- 38 -
Appendix A: List of Acronyms ARC Abnormal Runway Contact ADRM Aerodrome ANSP Air Navigation Service Provider ATC Air Traffic Control ATS Air Traffic Services ASRT Annual Safety Report Team BIRD Birdstrike CTOL Collisions with Obstacles during Take Off or Landing CFIT Controlled flight into terrain DIP Detailed Implementation Plan F-IN Fire/Smoke (Non-Impact) FDA Flight Data Analysis FOQA Flight Operations Quality Assurance GCOL Ground Collision RAMP Ground Handling GASP ICAO Global Aviation Safety Plan IATA International Air Transport Association ICAO International Civil Aviation Organization LOC-G Loss of Control - Ground LOC-I Loss of control - inflight MAC Mid Air Collision MTOW Maximum Take-off Weight MENA Middle East & North Africa (IATA Region) MID Middle East Region (ICAO Region) RAST Regional Aviation Safety Group RE Runway Excursion (departure or landing) RI Runway Incursion RS Runway Safety SEI Safety Enhancement Initiative SMS Safety Management System SOP Standard Operating Procedure SSP State Safety Programme SCF-NP System Component Failure-Non-Power Plant SCF-PP System Component Failure-Power Plant USOS Undershoot/Overshoot UAS Undesirable Aircraft State USOAP Universal Safety Oversight Audit Program WILD Wildlife
- 39 -
CREDITS
The RASG-MID thanks all those who contributed to the elaboration of this Annual Safety Report and
provided necessary support and information to the members of the MID Annual Safety Report Group (MID-ASRG). Special thanks go to:
Mr. Jehad Faqir,
International Air Transport Association (IATA)
Mr. Mohamed Smaoui, Mr. Mohamed Chakib, and Mashhor Alblowi International Civil Aviation Organization (ICAO)
-END-
- 40 -
